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Development Of a Prospective Anaphylaxis Registry-an Ongoing Initiative
Abstracts S185
J ALLERGY CLIN IMMUNOL VOLUME 123, NUMBER 2
Development Of a Prospective Anaphylaxis Registry-an Ongoing Initiative V. Manivannan, R. K. Dhillon, M. Bellolio, B. Palamari, L. G. Stead, W. W. Decker, R. L. Campbell; Mayo Clinic, Rochester, MN. RATIONALE: The goal of this study is to establish a prospective emergency department (ED) anaphylaxis registry. METHODS: Patients presenting with signs of allergic reaction were identified, and those who meet the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network 2nd symposium symptom criteria for anaphylaxis were enrolled. Enrollment involved medical record review, completion of a questionnaire and telephone follow up. RESULTS: Twenty-four patients were enrolled in the first 4 months. The mean age was 32.5 years, and 54.2% were male. Eleven cases of anaphylaxis occurred at home (45.8%), 4 at work (16.7%), and 9 in other places. Eleven (45.8%) came to the ED by car and 6 (25%) by ambulance. The median time from onset of symptoms to arrival was 80 minutes, 8 (33%) came within one hour. In those cases the precipitating factor was recognized, the median time since contact with the allergen and initiation of the symptoms was 15 minutes. The most common symptoms were angioedema (42%), urticaria (46%), pruritus (33%), dyspnea (63%) and tightness of throat (42%). Eight patients had prior prescriptions for self-injectable epinephrine, and 2 used it. Only 11 patients recognized that they were having an allergic reaction. Twelve were aware of the use of self-injectable epinephrine for treatment, 5 knew of support organizations, and 1 patient wore a medical alert bracelet. CONCLUSIONS: The development of an ED registry will provide prospective data on anaphylaxis. These early results underscore the need for continued education for patients with anaphylaxis.
708
Repeat Epinephrine Treatments For Food-related Allergic Reactions That Present To The Emergency Department A. Banerji1, A. Perkins1, B. Corel1, A. Caceres1, S. Rudders2, S. Clark3, C. A. Camargo1; 1Massachusetts General Hospital, Boston, MA, 2Children’s Hospital Boston, Boston, MA, 3Unniversity of Pittsburgh, Pittsburgh, PA. RATIONALE: To date, there are sparse data on epinephrine treatment for food-related allergic reactions. We sought to establish the frequency of 21 epinephrine doses for patients who present with food-related allergic reaction to the emergency department (ED). METHODS: We performed a chart review, at two academic centers, of all patients presenting to the ED for food allergy (ICD9CM codes 693.1, 995.0, 995.3, and 995.60-995.69) between 1/1/01 and 12/31/06. We focused on causative foods and treatments, including the number of epinephrine treatments given before and during the ED visit. RESULTS: The 402 patients had a median age of 30 (IQR, 21-39) years and the cohort was 60% female. A variety of foods provoked the allergic reaction, including peanuts (21%), crustaceans (14%) and tree nuts (12%). 49% received treatment before arrival to the ED, of which 36% received epinephrine (i.e., 18% of all patients). In the ED, patients received antihistamines (84%), corticosteroids (74%), inhaled albuterol (18%), and epinephrine (20%). Of those who received epinephrine in the ED, 10% received >1 dose. Overall, 11% (95% confidence interval, 7-18%) of patients given epinephrine received 21 doses over the course of their reaction. At ED discharge (74% of patients), only 16% were referred to an allergist and 46% were prescribed self-injectable epinephrine. CONCLUSIONS: Among ED patients with a food-related allergic reaction treated with epinephrine, 11% were given 21 doses. This study supports the recommendation that patients at risk for food-related anaphylaxis should carry two doses of epinephrine. Further study is needed to identify risk factors for repeat epinephrine use.
709
Higher Incidence of Pediatric Anaphylaxis in Southern Areas of the United States W. J. Sheehan2,1, D. A. Graham2,3, L. Ma4,5, W. Phipatanakul1,2; 1Children’s Hospital Boston, Division of Immunology, Boston, MA, 2Harvard Medical School, Boston, MA, 3Children’s Hospital Boston, Clinical Research Program, Boston, MA, 4Children’s Hospital Boston, Program for Patient Safety and Quality, Boston, MA, 5Children’s Hospital Boston, Division of Cardiology, Boston, MA. RATIONALE: Previous studies have suggested a north-south gradient of anaphylaxis with increased rates further from the equator. We examined the rates of pediatric anaphylaxis in the US, focusing on a north-south comparison. METHODS: We searched the Pediatric Health Information System (PHIS), a billing database of US free-standing pediatric hospitals, for all cases of anaphylaxis. All hospitals providing inpatient and ED information from 2003-2007 were studied and divided at the 39o longitude creating 12 northern and 13 southern pediatric hospitals. Anaphylaxis rates (per 1,000 visits) were analyzed for north-south differences. RESULTS: There were 16,629 anaphylaxis cases (56.7% male, median age 6.2 years) among 8.5 million patient encounters. Anaphylaxis incidence was 1.96 per 1,000 encounters. Sting anaphylaxis was five times more common than food anaphylaxis (1.13 vs. 0.20 per 1,000; OR 5 5.79; 95%CI 5 5.49-6.09; p < 0.001). Southern pediatric hospitals had higher anaphylaxis rates in the ED (2.08 vs. 1.87 per 1,000; p < 0.001) and admissions (2.13 vs. 1.60 per 1,000; p < 0.001) compared to northern hospitals. Sting anaphylaxis was more common in the south (1.44 vs. 0.83 per 1,000; p < 0.001). In contrast, food anaphylaxis was twice as likely in the north (0.26 vs. 0.13 per 1,000; OR 5 2.02; 95% CI 5 1.82-2.23; p < 0.001), although this represented a small proportion of the total cases. CONCLUSIONS: The incidence of anaphylaxis was 0.2% of all pediatric hospital visits. Overall anaphylaxis and sting specific anaphylaxis were higher in southern US cities. Food anaphylaxis was much less common overall, but occurred more frequently in northern US cities.
710
Inhibitory Effect Of Butanol Purified Herbal Formula FAHF-2 On Mast Cells Y. Song, J. Zhan, N. Yang, K. Srivastava, X. Li; Mount Sinai School of Medicine, New York, NY. RATIONALE: The food allergy herbal formula -2 (FAHF-2) has been shown to completely block the anaphylaxis reaction in murine model and is currently used in clinical study in US. To improve the convenience of patients in clinic, we generated an improved FAHF-2 product using butanol purification, which removed unnecessary components by approximately 80%. Mast cells are major effector cells involved in food -induced anaphylaxis. Thus, in this study, we determined the effect of butanol extracted FAHF-2 (B-FAHF-2) on activated mast cells. METHODS: Mast cells (MC/9) were cultured with or without DNP IgE. FAHF-2 at 250 mg/ml and B-FAHF-2 at 55 mg/ml (equivalent to 250 mg/ml of FAHF-2) were co-cultured for 48 h. Histamine levels in the culture supernatant triggered by DNP were measured using an enzyme immunoassay kit. Furthermore, since murine monocyte chemotactic protein-1 (MMCP1) is an important inflammatory chemokine that is secreted from activated mast cells, we also conducted a dose dependent study to measure MMCP1 production by DNP-primed mast cell. MMCP-1 in culture supernatants was measured by ELISA. RESULTS: FAHF-2 significantly reduced DNP triggered histamine release (p < 0.05). B-FAHF-2 at equivalent concentration was as effective as FAHF-2 in inhibiting histamine release (p < 0.05 vs untreated culture). Furthermore, as seen in FAHF-2, B-FAHF-2 showed dose dependent inhibition on MMCP-1 production by DNP-primed mast cell while at the much low doses than FAHF-2. CONCLUSIONS: This study shows that B- FAHF-2 suppressed mast cell activation as effective as original FAHF-2, but was at a much reduced doses, suggesting an optimal candidate for development of interventions for food allergy.
MONDAY
707
J ALLERGY CLIN IMMUNOL VOLUME 123, NUMBER 2
Development Of a Prospective Anaphylaxis Registry-an Ongoing Initiative V. Manivannan, R. K. Dhillon, M. Bellolio, B. Palamari, L. G. Stead, W. W. Decker, R. L. Campbell; Mayo Clinic, Rochester, MN. RATIONALE: The goal of this study is to establish a prospective emergency department (ED) anaphylaxis registry. METHODS: Patients presenting with signs of allergic reaction were identified, and those who meet the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network 2nd symposium symptom criteria for anaphylaxis were enrolled. Enrollment involved medical record review, completion of a questionnaire and telephone follow up. RESULTS: Twenty-four patients were enrolled in the first 4 months. The mean age was 32.5 years, and 54.2% were male. Eleven cases of anaphylaxis occurred at home (45.8%), 4 at work (16.7%), and 9 in other places. Eleven (45.8%) came to the ED by car and 6 (25%) by ambulance. The median time from onset of symptoms to arrival was 80 minutes, 8 (33%) came within one hour. In those cases the precipitating factor was recognized, the median time since contact with the allergen and initiation of the symptoms was 15 minutes. The most common symptoms were angioedema (42%), urticaria (46%), pruritus (33%), dyspnea (63%) and tightness of throat (42%). Eight patients had prior prescriptions for self-injectable epinephrine, and 2 used it. Only 11 patients recognized that they were having an allergic reaction. Twelve were aware of the use of self-injectable epinephrine for treatment, 5 knew of support organizations, and 1 patient wore a medical alert bracelet. CONCLUSIONS: The development of an ED registry will provide prospective data on anaphylaxis. These early results underscore the need for continued education for patients with anaphylaxis.
708
Repeat Epinephrine Treatments For Food-related Allergic Reactions That Present To The Emergency Department A. Banerji1, A. Perkins1, B. Corel1, A. Caceres1, S. Rudders2, S. Clark3, C. A. Camargo1; 1Massachusetts General Hospital, Boston, MA, 2Children’s Hospital Boston, Boston, MA, 3Unniversity of Pittsburgh, Pittsburgh, PA. RATIONALE: To date, there are sparse data on epinephrine treatment for food-related allergic reactions. We sought to establish the frequency of 21 epinephrine doses for patients who present with food-related allergic reaction to the emergency department (ED). METHODS: We performed a chart review, at two academic centers, of all patients presenting to the ED for food allergy (ICD9CM codes 693.1, 995.0, 995.3, and 995.60-995.69) between 1/1/01 and 12/31/06. We focused on causative foods and treatments, including the number of epinephrine treatments given before and during the ED visit. RESULTS: The 402 patients had a median age of 30 (IQR, 21-39) years and the cohort was 60% female. A variety of foods provoked the allergic reaction, including peanuts (21%), crustaceans (14%) and tree nuts (12%). 49% received treatment before arrival to the ED, of which 36% received epinephrine (i.e., 18% of all patients). In the ED, patients received antihistamines (84%), corticosteroids (74%), inhaled albuterol (18%), and epinephrine (20%). Of those who received epinephrine in the ED, 10% received >1 dose. Overall, 11% (95% confidence interval, 7-18%) of patients given epinephrine received 21 doses over the course of their reaction. At ED discharge (74% of patients), only 16% were referred to an allergist and 46% were prescribed self-injectable epinephrine. CONCLUSIONS: Among ED patients with a food-related allergic reaction treated with epinephrine, 11% were given 21 doses. This study supports the recommendation that patients at risk for food-related anaphylaxis should carry two doses of epinephrine. Further study is needed to identify risk factors for repeat epinephrine use.
709
Higher Incidence of Pediatric Anaphylaxis in Southern Areas of the United States W. J. Sheehan2,1, D. A. Graham2,3, L. Ma4,5, W. Phipatanakul1,2; 1Children’s Hospital Boston, Division of Immunology, Boston, MA, 2Harvard Medical School, Boston, MA, 3Children’s Hospital Boston, Clinical Research Program, Boston, MA, 4Children’s Hospital Boston, Program for Patient Safety and Quality, Boston, MA, 5Children’s Hospital Boston, Division of Cardiology, Boston, MA. RATIONALE: Previous studies have suggested a north-south gradient of anaphylaxis with increased rates further from the equator. We examined the rates of pediatric anaphylaxis in the US, focusing on a north-south comparison. METHODS: We searched the Pediatric Health Information System (PHIS), a billing database of US free-standing pediatric hospitals, for all cases of anaphylaxis. All hospitals providing inpatient and ED information from 2003-2007 were studied and divided at the 39o longitude creating 12 northern and 13 southern pediatric hospitals. Anaphylaxis rates (per 1,000 visits) were analyzed for north-south differences. RESULTS: There were 16,629 anaphylaxis cases (56.7% male, median age 6.2 years) among 8.5 million patient encounters. Anaphylaxis incidence was 1.96 per 1,000 encounters. Sting anaphylaxis was five times more common than food anaphylaxis (1.13 vs. 0.20 per 1,000; OR 5 5.79; 95%CI 5 5.49-6.09; p < 0.001). Southern pediatric hospitals had higher anaphylaxis rates in the ED (2.08 vs. 1.87 per 1,000; p < 0.001) and admissions (2.13 vs. 1.60 per 1,000; p < 0.001) compared to northern hospitals. Sting anaphylaxis was more common in the south (1.44 vs. 0.83 per 1,000; p < 0.001). In contrast, food anaphylaxis was twice as likely in the north (0.26 vs. 0.13 per 1,000; OR 5 2.02; 95% CI 5 1.82-2.23; p < 0.001), although this represented a small proportion of the total cases. CONCLUSIONS: The incidence of anaphylaxis was 0.2% of all pediatric hospital visits. Overall anaphylaxis and sting specific anaphylaxis were higher in southern US cities. Food anaphylaxis was much less common overall, but occurred more frequently in northern US cities.
710
Inhibitory Effect Of Butanol Purified Herbal Formula FAHF-2 On Mast Cells Y. Song, J. Zhan, N. Yang, K. Srivastava, X. Li; Mount Sinai School of Medicine, New York, NY. RATIONALE: The food allergy herbal formula -2 (FAHF-2) has been shown to completely block the anaphylaxis reaction in murine model and is currently used in clinical study in US. To improve the convenience of patients in clinic, we generated an improved FAHF-2 product using butanol purification, which removed unnecessary components by approximately 80%. Mast cells are major effector cells involved in food -induced anaphylaxis. Thus, in this study, we determined the effect of butanol extracted FAHF-2 (B-FAHF-2) on activated mast cells. METHODS: Mast cells (MC/9) were cultured with or without DNP IgE. FAHF-2 at 250 mg/ml and B-FAHF-2 at 55 mg/ml (equivalent to 250 mg/ml of FAHF-2) were co-cultured for 48 h. Histamine levels in the culture supernatant triggered by DNP were measured using an enzyme immunoassay kit. Furthermore, since murine monocyte chemotactic protein-1 (MMCP1) is an important inflammatory chemokine that is secreted from activated mast cells, we also conducted a dose dependent study to measure MMCP1 production by DNP-primed mast cell. MMCP-1 in culture supernatants was measured by ELISA. RESULTS: FAHF-2 significantly reduced DNP triggered histamine release (p < 0.05). B-FAHF-2 at equivalent concentration was as effective as FAHF-2 in inhibiting histamine release (p < 0.05 vs untreated culture). Furthermore, as seen in FAHF-2, B-FAHF-2 showed dose dependent inhibition on MMCP-1 production by DNP-primed mast cell while at the much low doses than FAHF-2. CONCLUSIONS: This study shows that B- FAHF-2 suppressed mast cell activation as effective as original FAHF-2, but was at a much reduced doses, suggesting an optimal candidate for development of interventions for food allergy.
MONDAY
707